Medicaid Cuts Limit Access to Oral Health Care

Congressional proposals to cut and cap Medicaid will put enormous pressure on states to cut services – and will make it nearly impossible for states that now have gaps in their coverage to ever catch up. The struggle to provide oral health care illustrates this problem. Currently, all states must provide oral health care for children, but oral health coverage for adults including seniors and people with disabilities is optional for states. While a number of states provide a robust dental benefit, many states do not yet. If their residents get care at all, they rely on sporadic charity care, such as that provided by traveling dental clinics that pull infected teeth.

The lack of oral health care for low-income adults in these states creates terrible problems both for people and for the health care system. For example, in Arizona over the last several years, Medicaid has not even covered emergency dental care. A fact sheet from the Arizona Alliance of Community Health Centers and The American Dental Association explains that this left people in pain; adults went to hospitals to get pain medication and antibiotics for their decayed and infected teeth, since they could not get treatment for the underlying oral health problems, contributing to hospital emergency room and inpatient dental costs of $31 million. For example, a community health center dental director reported treating an adult patient who had just spent three days in the hospital for a tooth infection, yet still needed an extraction upon release. “The patient spent three days in intensive care for something that could have been treated at [a] clinic.”

This legislative session, Arizona took action to authorize a limited emergency dental benefit – but advocates continue to work for a fuller benefit that will provide both preventive and restorative care as well. Likewise, advocates and officials in states such as Maryland and Maine are working towards improvements in their Medicaid oral health benefits.

However, states will not have money to improve Medicaid benefits under the House’s “American Health Care Act” or the Senate’s “Better Care Reconciliation Act” bill. A per capita cap formula for federal Medicaid spending, like the one both bills propose, would mean that if a state did improve its benefits, it would not get federal matching dollars for doing so. That is because the bills set states’ pre-2017 spending levels as a baseline, and only provide states with the same amount of federal Medicaid dollars per person that they received before 2017, with a slight adjustment for inflation. Thus, states with limited dental benefits would have to pay the full cost to catch up with other states that better address public health needs, which they do not have the state resources to do. And for many adults who received Medicaid when the Affordable Care Act expanded coverage, the situation is far worse.

Congressional proposals to end the Medicaid expansion for low-income adults will reverse the progress some states are making to provide preventive oral health care – and other health care – to working adults. Under the Affordable Care Act, states received enhanced federal matching funds to expand coverage to adults with incomes up to 138 percent of the federal poverty line, and this critical financial resource enabled many states to provide dental benefits to these newly covered adults. Data from several states that, under the Affordable Care Act, expanded Medicaid and that provide a robust dental care benefit illustrate that this coverage is valued and used.

• In Ohio, under the ACA Medicaid expansion, Medicaid coverage to low-income adults including the working poor began in 2014. By 2015, half (50%) of all Medicaid enrolled adults reported that they had a dental visit in the last year, a utilization rate comparable to that of privately insured adults nationally. In a 2016 survey, nearly two-thirds of Ohio expansion enrollees said that Medicaid had improved their access to dental care as well as to general health care.
• In Kentucky, 80,000 Medicaid expansion members received preventive dental services in 2014, the first year of the expansion – one-fourth of the people who gained coverage that year.
• In Montana, over 77,000 people have gained Medicaid coverage through the expansion and already, in the first year alone, over 26,500 of them have received preventive dental care. In fact, in the first year of the expansion, adult dental care was the top used preventive care service by newly insured adults. In total, expansion beneficiaries have received 187,000 dental services, including preventive, diagnostic, and restorative care.
• A national study using 2014 data notes that childless adults made significant gains in their access to and use of dental care in the year after Medicaid expansion.

But under Congressional proposals, the Medicaid expansion will end, leaving many low-wage working adults without any coverage.

Mary Otto’s recent book, Teeth, describes the hardships and stigma faced by people with poor teeth, and a vision for a transformed oral health care system that incentivizes disease prevention, “a system where dentists spend less time extracting and more time healing and where patients break the cycle of disease and pain and loss.” Only with decent coverage for all will we be able to break the silent epidemic of oral disease, and of other diseases that fall hardest on people who can least afford care.